Harmony Healthcare Blog

Compliance Series - 7 Elements: #2 Reporting and Investigating

Posted by Kris Mastrangelo on Thu, Jan 31, 2019


Edited by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency


Reporting.jpgAs a continuation of the 7 Part Blog Series on Compliance, today we will dive into Reporting and Investigating. 

P-R-E-P-A-R-E

  1. Policies and Procedures
  2. Reporting and Investigating
  3. Education and Training
  4. Prevention and Response
  5. Auditing and Monitoring
  6. Responsibility/Oversight of Compliance Officer/Committee
  7. Enforcement, Discipline and Incentives 

Reporting (A Complaint is A Gift)

Reporting refers to the organization’s system in which individuals have the ability to communicate concerns about non-compliance in an anonymous fashion.  It is very important to establish a culture that is receptive to feedback.  About two decades ago, while I was employed at Sun Healthcare Group, a woman named Lauren Murray (VP Marketing) chanted the saying “A Complaint is a Gift” to the Boston Region. Her point resonated with the team as she reinforced that “If you are lucky enough to hear the feedback, you have the ability to correct the problem.” I believe this saying applies to Compliance.  Treating feedback as a gift, versus a nuisance, is a powerful mindset and approach that will set the stage for success.

A commonly used methodology for reporting systems includes a hotline.  However, organizations may establish technological platforms, lock boxes, and other innovative forums for communication.

The Goals of the Reporting System include:

  • Ensure that all concerns are addressed timely and feedback is provided to the reporter (caller).
  • Reporting Systems are inclusive of methodologies  beyond a hotline. 
  • The reporter has the right to anonymity. However, the reporter is free to discuss if he or she is not concerned about discretion.
  • Implementation of internal checks to ensure that reporters are free of retaliatory actions.  I.e., The employee does not receive negative reactions by the organization due to voicing concerns.  
  • The Reporting System must be transparent, in that all entities (employees, business associates, and agents) are informed of the process.

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Investigations and Remedial Measures

Once a complaint is received, the most important next step is the investigation and the development of the action plan if noncompliance is detected.  The investigation must be conducted by an individual or entity with the appropriate skill set for the subject matter.  Collaboration with Legal Counsel is essential in order to  determine if Privilege is necessary. 

The Goals of the Investigation and Remedial Measures include: 

  • If noncompliance is detected, immediate implementation of corrective measures is necessary to mitigate further harm.  I refer to this as “stop the bleeding” as one would do on the battle field with a severed limb….the tourniquet.
  • The Investigative process for noncompliance must be conducted in an unbiased, objective, confidential fashion
  • Problem Solve a corrective action inclusive of a system that inherently prevents this issue from recurring.  This may take time and refinements.  The key component is the issue identified must be added to the monitoring program Once the issue is pinpointed, it must be prioritized and prevented from repeat offenses. The overarching goal is to reduce risk.
  • Preserve all documents and medical records that are relevant to the investigation.
  • If a governmental entity is involved, cooperation is essential.   The first question posed “How did the organization respond to a complaint?”  The correct answer: “We performed an investigation.” 
  • If overpayments to payers are detected, be mindful of the timelines imposed for payment of refunds

As always, I hope this helps with your Quest for Compliance!

Harmony Healthcare International (HHI) is available to provide assistance You can contact us by clicking here. Looking to train your staff?  Join us in person at one of our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 


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